Bowel Elimination / Ostomy Care, Urinary Catheterization, Module 17:
Lesson 6 Post-Test, NU 311 EXAM 4 Urinary Cath, Evolve - Urination,
Module 16 Urinary, N220: Oxygenation video quizzes, Hallmark final
exam BSN-205
Primary function of the GI structure:
1. Esophagus
2. Rectum
3. Small Intestine
4. Stomach
5. Colon
1. Where peristalsis moves food to the stomach.
2. Temporarily stores feces until elimination.
3. Receives enzymes from the gallbladder and pancreas to further break down chyme
and absorb nutrients.
4. Secretes hydrochloric acid and pepsin; converts bolus of food to chyme.
5. Absorbs, protects, secretes, eliminates.
Rationale:
The esophagus moves food to the stomach by peristaltic action. The stomach secretes
hydrochloric acid and pepsin and converts the food bolus to chyme. The small intestine
receives enzymes from the gallbladder and pancreas to further break down chyme.
Most absorption of nutrients occurs in the small intestine. The primary functions of the
colon (large intestine) are absorption, protection, secretion, and elimination. The rectum
temporarily stores feces until elimination.
If a patient had to have part of the colon (large intestine) removed, which of the
following may result?
The patient could experience an acid-base imbalance.
Rationale:
A primary function of the colon is secretion of bicarbonate for chloride and the release of
potassium. Any alteration in secretory function could result in an acid-base imbalance.
Another primary function of the colon is protection of the sensitive tissue lining of the
colon through the release of mucus. If a portion of the colon is removed, there would be
fewer mucus-secreting cells available. The colon also absorbs water, sodium, and
chloride. If less water is absorbed, the patient would be at increased risk for diarrhea
and an electrolyte imbalance.
A nurse is admitting a patient to the unit. The nurse is aware that the patient is at
increased risk for constipation if the following are present in the patient's health
history or admission assessment:
Select all that apply.
- the patient is an elderly woman
- the patient takes opioids for chronic back pain
- the patient takes daily iron and calcium supplements
,Rationale:
As a person ages, peristalsis slows, which increases the risk for constipation. Opioids,
iron supplements, and calcium supplements slow colonic action. Laxative misuse is a
common cause for constipation. A diet high in animal fats and low in fiber and fluid
increases the risk for constipation. Lengthy bed rest or lack of regular exercise are risk
factors for constipation.
A student nurse is studying the GI system in preparation for an exam. Which
statement indicates correct understanding?
"The ascending colon would be found in the right side of the patient's abdomen."
Rationale:
The ascending colon is found in the right side of the abdomen. The order of the colon is
ascending colon, transverse colon, descending colon, sigmoid colon (then rectum and
anus). Most nutrients are absorbed in the small intestine; most water is absorbed in the
large intestine. A patient's heart rate may decrease with manipulation of the rectum that
stimulates the vagus nerve (known as a vagal response). Opioids (narcotic analgesics)
cause constipation because of decreasing peristalsis; antibiotic therapy places a person
at risk for diarrhea as a result of altered normal flora (as seen with Clostridium difficile
infection).
An increase in venous pressure caused by liver disease can result in the
development of:
Hemorrhoids
Rationale:
Pressure leading to hemorrhoids can also occur from straining during defecation and
from pregnancy.
The comatose patient in the intensive care unit (ICU), who has not had a bowel
movement in 4 days, suddenly is incontinent of liquid stool. What should the
nurse suspect?
Impaction
Rationale:
Prolonged constipation followed by diarrhea that seeps around the impacted stool are
symptoms of a fecal impaction.
The nurse is monitoring the patient for a possible vagal response while removing
a fecal impaction. If the patient had a vagal response, what would the nurse most
likely observe?
A decrease in heart rate
Rationale:
The nurse should monitor the patient for a decrease in heart rate.
An adult patient is scheduled for an abdominal computed tomography (CT) scan.
Before the scan he must receive a cleansing tap water enema. The nurse should
prepare:
,1000 mL or less of tap water
Rationale:
A tap water enema usually contains 750 to 1000 mL for the adult. If castile soap were to
be added, the order would be for a soap suds enema. A Fleet enema is a hypertonic
enema and that would be noted on the order. Because the order is for a tap water
enema, the Fleet product would not be appropriate.
The health care provider has ordered a Fleet enema for a patient experiencing
constipation. Which of the following actions would require correction?
The nurse squeezes and releases the bottle several times until all of the solution has
entered the patient
Rationale:
Squeezing and releasing the bottle would create suction within the patient's rectum as
fluid would attempt to fill the negative pressure within the bottle. The pliable bottle
should be squeezed gently and rolled up from the bottom as the contents enter the
bowel. If too cold, the enema solution should be warmed to prevent abdominal
cramping. The protective cover should be removed to avoid accidental instillation of the
cap into the patient. The rectal tip is prelubricated, but more water-soluble jelly may be
added if needed.
An adult patient complains of cramping during the administration of an enema.
What could be a possible cause?
Select all that apply.
- the solution was instilled too rapidly
- the enema solution was too cold
Rationale:
One of the reasons for cramping is too rapid instillation of the solution. Slow the flow of
the solution by lowering the enema container. A cold solution may also cause
abdominal cramping. The patient should be in Sims' position and the lubricated rectal tip
inserted 3 to 4 inches.
Which of the following is the best example of documentation of enema
administration?
0830 800 mL tap water enema administered. Return clear with no fecal material Bowel
sounds present in all 4 quadrants pre and post procedure. Abdomen nondistended.
Patient states "I'm glad that's over."
Rationale:
Documentation of enema administration should include the type of enema given;
amount of fluid; characteristics of the fecal return; assessments before, during, and after
the procedure; any calls placed to health care provider; and patient's tolerance of the
procedure.
The nurse is observing the NAP administer a soap suds enema to an adult
patient. Which of the following actions, if made by the NAP, would require
correction?
, The NAP inserts the tip of the rectal tube 5 to 7 inches after lubricating it
Rationale:
The lubricated tip of the rectal tube should be inserted 3 to 4 inches on an adult (7.5 to
10 cm). Insertion beyond the proper limit could cause bowel perforation. The fluid bag is
typically placed 12 to 18 inches above the level of the patient's anus. The patient should
be placed in the Sims' position to allow the enema solution to flow downward by gravity
along the natural curve of the sigmoid colon and rectum, thus improving retention of the
solution. Priming the tubing removes air from the tubing.
A patient is to receive enemas "until clear." The nurse notes that stool remains in
the fecal return after the second enema. What should the nurse do?
Administer a third enema
Rationale:
The nurse should administer a third enema. If the nurse continues to see fecal matter in
the third return, the health care provider should be notified because too many large-
volume enemas can cause a serious fluid and electrolyte imbalance.
An infant is to have an enema. Which solution would the nurse anticipate using?
Normal saline
Rationale:
Normal saline is the safest type of solution. Infants and children can tolerate only this
type because of their predisposition to fluid imbalance.
The nurse is catheterizing a male patient. Which of the following demonstrates
correct understanding of the procedure? (Select all that apply.)
- The patient is placed in a supine position with legs slightly abducted.
- The nurse cleans the urethral meatus using a circular motion beginning at the meatus
and working outward in a spiral pattern.
- The nurse applies sterile gloves before opening the antiseptic solution and lubricant.
Match the clinical situation with the intervention:
(A) Apply condom catheter- Patient is an incontinent male who empties his bladder fully
(B) Consider prostate enlargement; may require Coudé catheter- Difficulty inserting
catheter with a male patient
(C) Insert indwelling catheter- Patient is going to have major abdominal surgery
(D) Patient is due to void between 4:00 PM and 6:00 PM- Indwelling catheter is
removed at 10 AM
(E) Ensure tubing/catheter is kink free, then assess patient for renal failure or for severe
dehydration- Urine output from indwelling catheter is less than 30 mL per hour
(F) Notify health care provider- Patient with indwelling catheter develops fever, elevated
pulse, lower abdominal pain, cloudy, foul-smelling urine
(G) Document the procedure- 16 French 5 mL indwelling catheter inserted; tolerated
well; output of 875 mL clear, yellow urine; pain free; urine specimen sent to lab
(H) Insert straight catheter- Patient needs a single sterile urine specimen
Match the type of catheter to the type of application:
Lesson 6 Post-Test, NU 311 EXAM 4 Urinary Cath, Evolve - Urination,
Module 16 Urinary, N220: Oxygenation video quizzes, Hallmark final
exam BSN-205
Primary function of the GI structure:
1. Esophagus
2. Rectum
3. Small Intestine
4. Stomach
5. Colon
1. Where peristalsis moves food to the stomach.
2. Temporarily stores feces until elimination.
3. Receives enzymes from the gallbladder and pancreas to further break down chyme
and absorb nutrients.
4. Secretes hydrochloric acid and pepsin; converts bolus of food to chyme.
5. Absorbs, protects, secretes, eliminates.
Rationale:
The esophagus moves food to the stomach by peristaltic action. The stomach secretes
hydrochloric acid and pepsin and converts the food bolus to chyme. The small intestine
receives enzymes from the gallbladder and pancreas to further break down chyme.
Most absorption of nutrients occurs in the small intestine. The primary functions of the
colon (large intestine) are absorption, protection, secretion, and elimination. The rectum
temporarily stores feces until elimination.
If a patient had to have part of the colon (large intestine) removed, which of the
following may result?
The patient could experience an acid-base imbalance.
Rationale:
A primary function of the colon is secretion of bicarbonate for chloride and the release of
potassium. Any alteration in secretory function could result in an acid-base imbalance.
Another primary function of the colon is protection of the sensitive tissue lining of the
colon through the release of mucus. If a portion of the colon is removed, there would be
fewer mucus-secreting cells available. The colon also absorbs water, sodium, and
chloride. If less water is absorbed, the patient would be at increased risk for diarrhea
and an electrolyte imbalance.
A nurse is admitting a patient to the unit. The nurse is aware that the patient is at
increased risk for constipation if the following are present in the patient's health
history or admission assessment:
Select all that apply.
- the patient is an elderly woman
- the patient takes opioids for chronic back pain
- the patient takes daily iron and calcium supplements
,Rationale:
As a person ages, peristalsis slows, which increases the risk for constipation. Opioids,
iron supplements, and calcium supplements slow colonic action. Laxative misuse is a
common cause for constipation. A diet high in animal fats and low in fiber and fluid
increases the risk for constipation. Lengthy bed rest or lack of regular exercise are risk
factors for constipation.
A student nurse is studying the GI system in preparation for an exam. Which
statement indicates correct understanding?
"The ascending colon would be found in the right side of the patient's abdomen."
Rationale:
The ascending colon is found in the right side of the abdomen. The order of the colon is
ascending colon, transverse colon, descending colon, sigmoid colon (then rectum and
anus). Most nutrients are absorbed in the small intestine; most water is absorbed in the
large intestine. A patient's heart rate may decrease with manipulation of the rectum that
stimulates the vagus nerve (known as a vagal response). Opioids (narcotic analgesics)
cause constipation because of decreasing peristalsis; antibiotic therapy places a person
at risk for diarrhea as a result of altered normal flora (as seen with Clostridium difficile
infection).
An increase in venous pressure caused by liver disease can result in the
development of:
Hemorrhoids
Rationale:
Pressure leading to hemorrhoids can also occur from straining during defecation and
from pregnancy.
The comatose patient in the intensive care unit (ICU), who has not had a bowel
movement in 4 days, suddenly is incontinent of liquid stool. What should the
nurse suspect?
Impaction
Rationale:
Prolonged constipation followed by diarrhea that seeps around the impacted stool are
symptoms of a fecal impaction.
The nurse is monitoring the patient for a possible vagal response while removing
a fecal impaction. If the patient had a vagal response, what would the nurse most
likely observe?
A decrease in heart rate
Rationale:
The nurse should monitor the patient for a decrease in heart rate.
An adult patient is scheduled for an abdominal computed tomography (CT) scan.
Before the scan he must receive a cleansing tap water enema. The nurse should
prepare:
,1000 mL or less of tap water
Rationale:
A tap water enema usually contains 750 to 1000 mL for the adult. If castile soap were to
be added, the order would be for a soap suds enema. A Fleet enema is a hypertonic
enema and that would be noted on the order. Because the order is for a tap water
enema, the Fleet product would not be appropriate.
The health care provider has ordered a Fleet enema for a patient experiencing
constipation. Which of the following actions would require correction?
The nurse squeezes and releases the bottle several times until all of the solution has
entered the patient
Rationale:
Squeezing and releasing the bottle would create suction within the patient's rectum as
fluid would attempt to fill the negative pressure within the bottle. The pliable bottle
should be squeezed gently and rolled up from the bottom as the contents enter the
bowel. If too cold, the enema solution should be warmed to prevent abdominal
cramping. The protective cover should be removed to avoid accidental instillation of the
cap into the patient. The rectal tip is prelubricated, but more water-soluble jelly may be
added if needed.
An adult patient complains of cramping during the administration of an enema.
What could be a possible cause?
Select all that apply.
- the solution was instilled too rapidly
- the enema solution was too cold
Rationale:
One of the reasons for cramping is too rapid instillation of the solution. Slow the flow of
the solution by lowering the enema container. A cold solution may also cause
abdominal cramping. The patient should be in Sims' position and the lubricated rectal tip
inserted 3 to 4 inches.
Which of the following is the best example of documentation of enema
administration?
0830 800 mL tap water enema administered. Return clear with no fecal material Bowel
sounds present in all 4 quadrants pre and post procedure. Abdomen nondistended.
Patient states "I'm glad that's over."
Rationale:
Documentation of enema administration should include the type of enema given;
amount of fluid; characteristics of the fecal return; assessments before, during, and after
the procedure; any calls placed to health care provider; and patient's tolerance of the
procedure.
The nurse is observing the NAP administer a soap suds enema to an adult
patient. Which of the following actions, if made by the NAP, would require
correction?
, The NAP inserts the tip of the rectal tube 5 to 7 inches after lubricating it
Rationale:
The lubricated tip of the rectal tube should be inserted 3 to 4 inches on an adult (7.5 to
10 cm). Insertion beyond the proper limit could cause bowel perforation. The fluid bag is
typically placed 12 to 18 inches above the level of the patient's anus. The patient should
be placed in the Sims' position to allow the enema solution to flow downward by gravity
along the natural curve of the sigmoid colon and rectum, thus improving retention of the
solution. Priming the tubing removes air from the tubing.
A patient is to receive enemas "until clear." The nurse notes that stool remains in
the fecal return after the second enema. What should the nurse do?
Administer a third enema
Rationale:
The nurse should administer a third enema. If the nurse continues to see fecal matter in
the third return, the health care provider should be notified because too many large-
volume enemas can cause a serious fluid and electrolyte imbalance.
An infant is to have an enema. Which solution would the nurse anticipate using?
Normal saline
Rationale:
Normal saline is the safest type of solution. Infants and children can tolerate only this
type because of their predisposition to fluid imbalance.
The nurse is catheterizing a male patient. Which of the following demonstrates
correct understanding of the procedure? (Select all that apply.)
- The patient is placed in a supine position with legs slightly abducted.
- The nurse cleans the urethral meatus using a circular motion beginning at the meatus
and working outward in a spiral pattern.
- The nurse applies sterile gloves before opening the antiseptic solution and lubricant.
Match the clinical situation with the intervention:
(A) Apply condom catheter- Patient is an incontinent male who empties his bladder fully
(B) Consider prostate enlargement; may require Coudé catheter- Difficulty inserting
catheter with a male patient
(C) Insert indwelling catheter- Patient is going to have major abdominal surgery
(D) Patient is due to void between 4:00 PM and 6:00 PM- Indwelling catheter is
removed at 10 AM
(E) Ensure tubing/catheter is kink free, then assess patient for renal failure or for severe
dehydration- Urine output from indwelling catheter is less than 30 mL per hour
(F) Notify health care provider- Patient with indwelling catheter develops fever, elevated
pulse, lower abdominal pain, cloudy, foul-smelling urine
(G) Document the procedure- 16 French 5 mL indwelling catheter inserted; tolerated
well; output of 875 mL clear, yellow urine; pain free; urine specimen sent to lab
(H) Insert straight catheter- Patient needs a single sterile urine specimen
Match the type of catheter to the type of application:
